Most group policies that you obtain as a result of your employment are governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA is a federal statute that provides extremely strict deadlines and guidelines for claimants and insurance companies to abide by in the processing of a claim, submission of an appeal, and ultimately the determination of eligibility for benefits under a disability insurance policy. Most significant, ERISA creates an unequal claims process, placing strict obligations on individuals pursuing benefits that make maneuvering a claim difficult and frustrating for unaware claimants at a time when they should be focusing on their recovery. If you are applying for benefits or have been denied benefits under an ERISA governed Plan, you should be aware of your obligations in proving your claim and the strict deadlines you are working under. The question is, do you have the right information to be successful when applying for benefits under or appealing a denial of your disability insurance claim?
When a claim for disability benefits governed by ERISA is denied, the claimant MUST submit an administrative appealing a denial directly to the insurance company that originally denied the claim. If you do not, you may be barred from further pursuing your claim. If your insurance company upholds its denial of your claim following the submission of all mandatory appeals, you may then file a lawsuit. However, most claimants do not understand that typically the only information that you may present at trial is the information gathered during the application and appeals process. Accordingly, before you submit any information or respond in any way, you should thoroughly understand your rights and obligations. This is because in submitting an administrative appeal, you are essentially preparing your trial. Most individuals would not think about preparing for and facing their insurance company and its lawyers in court, without legal counsel. However, in submitting an administrative appeal unprepared, this is exactly what they are doing.
Claimants in ERISA governed disability claims do not have a right to a jury trial. Instead, you must present your case to a single judge. Moreover, at trial you are not proving that you are disabled, but are required to show that your insurance company acted unreasonably or in its own financial self interest when it made the decision to deny your claim for benefits. As such, ERISA places a much higher burden on claimants in a lawsuit. Moreover, insurance companies understand the burden that claimants are facing and claims examiners are well versed in how to prepare a denial to make it appear reasonable. For this reason, it is essential that claimants put all the necessary information in their applications and appeals, including statements from witnesses, physicians, independent experts, and employers. Anything left out, will likely never be allowed in court.
These cases are highly technical and insurance companies spend millions of dollars a year to scrutinize and defend against these claims. They hire private investigators to conduct surveillance of claimants in an attempt to create the illusion that the claimant has more functionality than claimed. They employ and pay physicians significant amounts of money to “evaluate” these cases, either through a paper review of claimants’ medical records or by requiring claimants to undergo examinations by their doctors. Often, insurance companies and their physicians simply cherry-pick the medical records – emphasizing anything that would suggest a lack of disability and ignoring all information that supports a claimant’s inability to work. Accordingly, it is essential that you provide sufficient information to combat against these common tactics and support your claim. This typically requires obtaining your own independent medical expert opinion and providing detailed narratives about your condition from your physicians. However, it is important to remember that insurance companies often take claimants’ and their physicians’ statements out of context to support a denial of benefits. Thus, it is essential that you and your physicians chose your words carefully when providing any information to your insurance company.
Many denials can be overturned prior to litigation, by effectively preparing an ERISA appeal. If you are considering hiring an attorney to help you apply for benefits or appeal an ERISA claim denial, it is essential that you choose an attorney with the knowledge and experience necessary to handle these complex legal issues. The attorneys at Disability Insurance Law Group aggressively represent claimants at all stages of their disability claims.